COVID-19 Test Appointment & Consent Form
Rapid COVID-19 Testing; Same Day Results; Cost: $125
Select a 5-minute time slot for your COVID-19 Testing Appointment
*
Submitter Name
Submitted Test Result to State [MONTH (MM)] - Post Test
Submitted Test Result to State [Day (DD)] - Post Test
Submitted Test Result to State [YEAR (YY)] - Post Test
Pharmacist Name (ordered the test)
Pharmacist NPI
Date Swab Performed [MONTH (MM)] - Post Test
Date Swab Performed [DAY (DD)] - Post Test
Date Swab Performed [YEAR (YYYY)] - Post Test
Test Result (Post test)
Detected/Positive
Not detected/Negative
Inconclusive/Undetermined/Invalid/Equivocal
Type of Facility
Pharmacy
Specimen Type
Nasal
Test Name
BD Veritor System for Rapid Detection of SARS-CoV-2
Patient Identifier
N/A
Patient Name
*
First name
Middle name
Last name
Date of birth (MM/DD/YYYY)
*
/
Month
/
Day
Year
Date
Age
*
Address
*
Street Address (and unit/apt # if applicable)
Street Address Line 2
City
State / Province
Zip code
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
You may choose a different option if your State is different
County of Residence
*
Please Select
Adams
Asotin
Benton
Chelan
Clallam
Clark
Columbia
Cowlitz
Douglas
Ferry
Franklin
Garfield
Grant
Grays Harbor
Island
Jefferson
King
Kitsap
Kittitas
Klickitat
Lewis
Lincoln
Mason
Okanogan
Pacific
Pend Oreille
Pierce
San Juan
Skagit
Skamania
Snohomish
Spokane
Stevens
Thurston
Wahkiakum
Walla Walla
Whatcom
Whitman
Yakima
You may choose a different option if your County is different
Phone Number
*
Format: (000) 000-0000.
Sex at birth
*
Female
Male
Neither/Other
Unknown
Select the most appropriate status below regarding pregnancy
*
Pregnant
Postpartum
Unknown
Neither pregnant nor postpartum
Race (select all that apply)
*
Unknown
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Other race (specify)
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Unknown
Do you have any symptoms?
*
Yes
No
Unknown
List your symptoms (if applicable)
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
Email Address (optional)
example@example.com
In addition to a phone call about your test results, please select your preference for an email notification.
I would like to receive my test results via an unsecured email from Duvall Family Drugs that is not HIPAA Compliant.
I DO NOT want to receive my test results via an unsecured email; I will come by the pharmacy drive through to receive a hard copy.
Signature
*
What is the patient's affiliation to the facility
Resident
Staff
Patient
Student
Client
Inmate
Did the patient die?
Yes
No
Unknown
Submit
Should be Empty: